Policy changes to implement the NHS five year forward view: a progress report

Five year forward view: two years on

Two years on from the publication of the NHS five year forward view, we assess how much progress has been made and what still needs to be done to align policies with the plan.

Introduction

In October 2014, NHS England and other arms-length bodies published the NHS five year forward view (Forward View). The Forward View set out a vision of how NHS services need to change to meet the needs of the population. It argued that the NHS should place far greater emphasis on prevention, integration of services, and putting patients and communities in control of their health.

The Forward View differed from previous policy documents; instead of setting out a blueprint for the future, it outlined a number of care models that can be adapted to put in place services appropriate to the needs of local populations. The emphasis was on ‘diverse solutions and local leadership, in place of further structural distraction’ supported by ‘meaningful local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied’ (p 4).

In February 2015, The King’s Fund set out the main policy changes we thought were required to make a reality of the Forward View. These included changes in how NHS services are commissioned and paid for, how NHS organisations are supported to make improvements in care, and how a transformation fund could contribute. We argued that national bodies needed to provide clear and consistent leadership on these and other issues in order to support implementation.

In the two years that have elapsed since publication of the Forward View, the NHS has been testing new models of care across the country at 50 ‘vanguard’ sites. Local leaders have been asked to come together into 44 areas, identified as geographical ‘footprints', and draw up sustainability and transformation plans (STPs) that map out how they intend to transform services in their local areas within the funding available to them. And national NHS bodies such as NHS England, NHS Improvement and the Care Quality Commission have made some changes to the regulation of the NHS to support implementation.

The past two years have also seen growing financial pressures on the NHS. Most providers are in deficit, key targets for patient care are being missed, and there are shortages of staff in some areas of care. Cuts to funding for social care and public health have also added to the challenges facing NHS organisations in meeting the demands placed on them. National and local leaders have been preoccupied with tackling these pressures, as well as embracing the transformational changes at the heart of the Forward View.

This progress report assesses what changes have already been made in the implementation of the Forward View and highlights what still needs to be done to align policies with the plan. We focus specifically on the policy changes we called for after the publication of the Forward View and don’t address policies and programmes in other areas – such as IT and infrastructure - or wider issues related to communities and public health.

How services are commissioned and paid for

How services are commissioned and paid for

Commissioning and contracting

What we said

National bodies should support NHS commissioners to implement new forms of commissioning and contracting. This should include establishing a community of practice to share learning and expertise, and offering expert legal and other advice.

What’s been done?

Innovations in commissioning and contracting to support integrated care predate the Forward View. Some of these innovations were led by primary care trusts and some by clinical commissioning groups. Examples include the use of alliance contracts, lead providers working with partners, and joint commissioning between the NHS and local government.

NHS England and other national bodies have been supporting and funding vanguard sites to develop new care models, including work on primary and acute care systems (PACS) and multispecialty community providers (MCPs) (see below). Innovations have been driven locally, and vanguards have worked together in learning networks to share experiences. Early indications from the care home vanguards suggest that their work has the potential to be implemented more rapidly than other new care models.

Recent reports from national bodies have summarised progress made in PACS, MCPs and care home models. The most advanced models are putting in place agreements on contracts and funding using alliance contracts, lead providers, Section 75 agreements with local authorities, capitated budgets and related approaches. This work is complex and time consuming and many of the PACS and MCPs will not operate under new contracts until 2017 or 2018. NHS Improvement has issued guidance that covers a number of aspects of new organisational forms.

Ambitious plans to integrate services under a long-term contract were attempted outside the vanguards programme with the UnitingCare Partnership for older people in Cambridgeshire and Peterborough. Though the contract collapsed due to financial issues, it represented an attempt to base a proportion of payment to providers on outcomes of care. The collapse of the contract highlighted the importance of mature governance and assurance arrangements and positive relationships between providers and commissioners.

What still needs to happen?

National bodies should continue to provide support to local areas and remove barriers to progress. They should also continue to capture learning and disseminate the results to areas not involved in the programme. This includes sharing expert legal and other advice to avoid wasteful duplication of resources and effort across the NHS. Information about the commissioning and contracting of the new care models should be documented and shared to support roll-out to other areas.

Multispecialty community providers (MCPs)

What we said

NHS commissioners should work with interested and capable general practices operating at sufficient scale to establish MCPs that take control of a capitated budget to deliver integrated out-of-hospital services. National bodies should provide access to learning from relevant experience of other health care systems

What’s been done?

In March 2015, NHS England selected 14 sites to become MCP vanguards, providing support and funding to facilitate their development.

MCPs are population-based models of care led by GPs that deliver a combination of primary and community health and care services in addition to bringing some services out into the community that have traditionally been provided in hospitals. MCPs consist of partnerships between GPs, community trusts and others depending on local context, including acute trusts, voluntary organisations and local authorities. MCPs have the potential to enable GPs to come together and take a broader leadership role in their local communities.

An MCP framework document, published by NHS England in July 2016, describes the underpinning service model, ranging from supporting whole populations to stay well through changing unhealthy behaviours and encouraging self-management, through to providing a more extensive service for those with the highest need, for example by developing care plans to support frail older people.

To support the delivery of these services, three broad contracting models are emerging: a ‘virtual’ MCP, where providers exist in an ‘alliance’ but no new contracts are signed; a ‘partially integrated’ MCP where commissioners bring together budgets and re‑procure a group of services (excluding core primary care) within a single contract; and a ‘fully integrated’ MCP that holds a single, whole population budget with all services in scope re-procured under 10- to 15-year contracts.

GPs involved in MCPs have come together in various ways including through federations and partnerships operating on a much larger scale than practices have typically done in the past. These new primary care-led organisations are still developing, and recent research has raised questions as to whether they will be able to assume responsibility for a population-based contract and its associated funding. One option is for GPs to partner with an established NHS provider to do so.

NHS England is working closely with six MCPs with the aim of publishing a final MCP contract early in 2017.

What still needs to happen?

No contracts have been let to an MCP thus far, and it will be April 2017 at the earliest before this happens. Emerging primary care-led organisations need more time and support to become established and to deliver on their promise. This includes establishing robust forms of organisational and clinical governance to ensure that public resources are spent effectively. Strong relationships between partner organisations and their leaders will be key to the effectiveness of MCPs.

Primary and acute care systems (PACS)

What we said

Different options for PACS should be explored, recognising the cultural differences between GPs and hospital clinicians and concerns that community services and GPs could become the poor relations. These options should include PACS being established as virtual organisations as well as single organisations.

What’s been done?

In March 2015 NHS England selected nine sites to become integrated primary and acute care systems (PACS) vanguards, providing support and funding to facilitate their development.

Like an MCP, a PACS is a population-based model of care that encompasses acute, primary, community, mental health and in some cases social care. One of the differences between the two models is their scale and scope: PACS usually cover larger populations and geographical areas and include most hospital services. They are also led by acute hospitals.

NHS England published its framework on PACS in September 2016, which outlines the emerging service models being developed in the nine sites. Key elements include supporting whole populations by building shared care records, supporting self-care and linking people with community services, and providing more co-ordinated inpatient care with improved discharge to community care for those with the highest needs.

As with MCPs, the PACS framework describes three broad contracting models: a ‘virtual’ PACS, a ‘partially integrated’ PACS and a ‘fully integrated’ PACS. It states that there will be an assurance process to assess the readiness of PACS to take on population-based budgets linked to the delivery of agreed outcomes. The most advanced PACS have set out their ambitions to become accountable care organisations or systems.

What still needs to happen?

PACS with a history of collaborative working like Northumbria and Salford are well into the implementation of their plans. Others are making progress but have more work to do to establish their approaches. All areas are working hard to engage GPs in their plans and this is universally recognised as a priority.

Like MCPs, PACS face the twin challenges of developing appropriate governance and leadership among the providers involved and strengthening relationships between organisations. They also rely on commissioners being able to implement new and often complex contracts (see above). This includes managing different accountabilities in the NHS and local government.

Incentives to support new models of care

What we said

NHS England and Monitor should accelerate the development of new payment systems such as capitated budgets, pooled budgets and integrated personal commissioning. They should strengthen their own capabilities for doing this work.

What’s been done?

In December 2014, NHS England and Monitor (as it was then) set out their plan for reforming the NHS payment system by developing new models of payment based on capitated budgets and outcomes-based payments to support new models of care. Following this, they published a collection of guidance documents with local examples of capitated budgets, risk sharing and outcome-based payment models.

In August 2016, NHS Improvement issued further guidance, which included advice on how providers might develop new approaches to payment, and has been running events and webinars to support local leaders. NHS England and NHS Improvement have been working jointly to develop a handbook describing the approaches to payment for new care models; this includes guidance on implementing:

  • a ‘whole population budget’, or single capitated budget available to the new entity
  • ‘payment for performance’ scheme to incentivise improvements in service quality
  • ‘gain/loss share agreement’ to enable local systems to share risk between organisations.

Further detail on the financial strategy for MCP and PACS is due to be published alongside the draft MCP contract later this year. The vanguards and other areas are making local contributions to innovation around payment systems.

Integrated personal commissioning is also being piloted. Nine ‘demonstrator sites’ are working with a chosen cohort of patients who have high levels of need across both health and social care. These sites are supporting patients to both plan their own care and manage their own health and care budgets.

What still needs to happen?

Changes to payment systems, and particularly the use of capitated, population-based budgets, is a fundamental building block of both the MCPs and PACS. While the emphasis on innovations being led locally is welcome, more support is needed from national bodies on the complex technical and other challenges involved. These challenges include how to determine the size of the budget (recognising the problems in the UnitingCare Partnership contract) and arrangements for sharing risks and rewards. In the absence of national support, the NHS may have to resort to expensive advice from consultancies.

How the NHS is regulated

How the NHS is regulated

Assessing the quality of local systems of care

What we said

The Care Quality Commission (CQC) should move quickly to assess how well care is integrated in local systems of care for groups such as older people. It should survey patients and service users to understand their experiences of whether care was well co-ordinated.

What’s been done?

CQC has carried out national studies along pathways of care, focusing on end-of-life care, services for people with dementia and integrated care for older people. It has also carried out three exercises to assess quality across an area, exploring what type of assessment (particularly in terms of depth and usefulness) can be achieved with reasonable resources and time.

It found that assessments could be produced by focusing on specific issues (such as co-ordination when transferring from hospital to home-based care) and specific population groups (such as over 75s). CQC designated the encouragement of new care models and innovation as one of four strategic priorities and has published a statement of intent on how it will take this forward, signalling a consultation on an evolution of the overall approach to inspection from April 2017.

NHS Improvement has published a new single oversight framework, which states a commitment to working more closely with CQC in the regulation of local systems of care. This includes developing a shared view of what good governance and leadership look like, and working towards a single combined assessment of quality and use of resources by NHS providers.

What still needs to happen?

CQC should ensure that the regulation of individual providers does not inhibit the development of place-based systems. It should build on what it has done so far and take the initiative in its forthcoming consultation to stimulate debate on future approaches to quality regulation across systems of care, keeping in mind the need to simplify regulation and ensure it is proportionate.

Consideration should be given to what, if any, role CQC’s assessment of providers (including how well-led they are) should have in authorising and overseeing them as suitable to lead new care models, such as hospital chains and collaborations. A balance must be struck between properly assuring new models and not preventing innovation at pace. The assessment of how well-led providers are (including their ability to provide assurance themselves, rather than relying only on external assurance) is likely to be important in this.

A whole-system intervention regime

What we said

NHS England, Monitor and the NHS Trust Development Authority should extend the use of interventions in whole health economies. They should avoid intervening in individual organisations in ways that conflict with this.

What’s been done?

Three ‘success regime’ areas were set up by the national oversight bodies, covering areas with signs of systemic problems. National bodies selected these areas and provided support and resources for in-depth diagnosis in order to understand the problems and develop plans for addressing them. The success regime areas have published plans and updates outlining the changes needed to ensure the sustainability and improvement of services in their areas.

STPs were not mentioned in the Forward View but have emerged as the main vehicle for planning services across geographical areas in England. Each success regime has been integrated into their local STP. NHS England and NHS Improvement are working together to provide support and oversight of the 44 STPs established in England in early 2016, following their announcement in NHS shared planning guidance in December 2015. They are also collaborating with other national bodies such as Health Education England and Public Health England.

STPs have been asked to produce ‘place-based’ plans for how services will be delivered in their area - centred on local populations rather than the individual organisations. The plans cover all areas of NHS spending - including specialised services and primary care - as well as focusing on better integration with social care and other local authority services. STPs are expected to set out how services will be transformed in line with the Forward View and how organisations will work together to live within the funding available to them.

Planning guidance issued in September 2016 indicates that STPs will become the core units of planning and contracting in future and that NHS England and NHS Improvement will work together to ensure alignment of commissioner and provider plans. This is a further sign that regulators intend to collaborate in their approaches to support local areas.

What still needs to happen?

The aim of national leaders to work together in overseeing the commissioning and provision of NHS services needs to be reflected at all levels in their organisations to ensure consistency of approach. STPs must develop their governance and leadership to fulfil their responsibilities and they must acquire capabilities to support implementation of their plans. These plans should be stress-tested to ensure that they are credible and that the financial assumptions on which they are based are robust.

Procurement and tendering

What we said

NHS England and Monitor should review current rules on procurement and tendering to remove any barriers to the development of new care models, and provide access to legal advice. Where appropriate they should provide a waiver to enable commissioners to depart from these rules.

What’s been done?

The Forward View committed national bodies to creating ‘flexibilities in the current regulatory, funding and pricing regimes’ and, more generally, to supporting the dissemination of learning from the vanguards. The main ways in which this has been taken forward are:

  • a brief guidance note by NHS Improvement to clarify when a full tendering process is required and when alternative options may be suitable, supported by a dedicated team offering advice to commissioners
  • the framework for MCPs and PACS issued by NHS England, which includes guidance on how new care models should be commissioned and procured.

Commissioners are exploring a variety of approaches to contracting for new care models. The PACS sites are furthest ahead in doing this. In Salford, commissioners undertook an assessment of the range of options to create an integrated care organisation and of the most capable prime providers before awarding the contract.

In Northumbria, a prior information notice was used to identify potential bidders for the PACS contract. The principal foundation trust was identified as the preferred provider, avoiding the need for a competitive process. Commissioners in Somerset initially considered a non-competitive process to confirm their PACS providers, but have now reverted to a ‘light touch’ procurement process to comply with the regulatory framework. Most of the PACS sites recognise that established NHS providers are likely to take on a lead role in the delivery of new care models.

MCPs are just beginning their procurement processes. MCPs in Dudley and West Wakefield are likely to hold a competitive dialogue process through which they discuss different options with a small number of bidders before choosing a solution. Dudley CCG started its procurement process in July 2016 and aims to award the MCP contract in April 2017; the intention is for the new provider system to be established by April 2018.

What still needs to happen?

Despite guidance and advice by national bodies, vanguards are uncertain what the law requires them to do. Commissioners must decide how to implement new care models while avoiding unnecessary cost and complexity and the prospect of legal challenge. National bodies should clarify these issues as a matter of urgency.

Another consideration is a desire to build productive relationships with local providers and not to undermine these relationships by going down an adversarial tendering route. The increasing role of local authorities in commissioning health services and as partners in STPs and vanguards introduces further rules and accountabilities that must be considered.

How improvements in care are delivered by local leaders

How improvements in care are delivered by local leaders

Leadership and improvement expertise

What we said

National bodies should develop a strategy for quality improvement and leadership development for the NHS in England to enable it to become a learning organisation. This should be based on the presumption that the main responsibility lies with NHS organisations, with national support for improvement being provided through small teams of credible experts.

What’s been done?

NHS Improvement, which was established in April 2016 through the merger of Monitor and the NHS Trust Development Authority, has the principal responsibility for quality improvement and leadership development for the NHS. Its business plan for 2016/17 laid out its priorities to: develop a national strategy for quality improvement and leadership development; implement a talent management scheme to help fill undesirable executive positions; build capacity and capability for continuous quality improvement; and develop an Emergency Care Improvement Plan. Its leaders have argued that more emphasis should be given to improvement alongside regulation.

The details of the national strategy for quality improvement and leadership development are still being finalised. Early signs show that the national bodies recognise the need to support local leaders and organisations to drive improvement from within the NHS. The strategy is expected to contain commitments to enable a more supportive approach to assessment, regulation and oversight; develop compassionate and inclusive leadership across all levels; and spread knowledge of quality improvement methods.

The strategy is being developed at a time when there are continuing concerns about recruitment to top leadership roles and increasing reliance on the use of interims in challenged organisations. Regulation and performance management have created insecurity for top leaders and this has often meant a shortage of qualified applicants when chief executive and other senor roles have become vacant.

What still needs to happen?

The stated aim of national bodies is that the NHS should harness the intrinsic motivation of staff to deliver the best possible care by giving them the resources, time and expertise to do so. This aim is consistent with statements from the Health Secretary that the NHS should become a learning system. The challenge will be to ensure that the actions of national bodies are aligned behind the emerging quality improvement and leadership development strategy and that renewed efforts are made to develop a pipeline of leaders for the future. While robust oversight of performance is necessary, more support should be available for the leaders of challenged organisations. The NHS at all levels needs to strengthen capabilities for quality improvement.

System leadership

What we said

National bodies and NHS organisations should prioritise the development of system leadership both for the NHS as a whole and in local health economies. This should include learning from other sectors and moving beyond the pace-setting styles that have been dominant in the recent past.

What’s been done?

Place-based approaches to commissioning and providing health and social care have developed significantly. This includes devolution of powers from central government, with Greater Manchester being the leading example where local authorities and NHS organisations are working together both across the conurbation and in localities to sustain and transform services. Governance and leadership arrangements in Greater Manchester are further advanced than in other areas of the country.

As discussed above, STPs are an increasingly important example of system leadership across 44 areas in England. STP leaders have been identified from NHS providers, NHS commissioners or local authorities, usually supported by partnership boards including representatives of the organisations involved in developing the plans. Resources, structures and processes to support STPs have been agreed locally, with many of those in leadership roles in STPs being seconded or released from their organisations.

The involvement of local authorities in Greater Manchester and, where it has occurred, in STPs, has helped the development of system leadership. This reflects the experience of local government leaders in working across organisational and service boundaries and building partnerships with others. Some support has been offered by organisations involved in leadership development, including The King’s Fund, recognising the need to lead in different ways in both STPs and new care models.

What still needs to happen?

STPs have no statutory basis and rely on the willingness of organisations to work in this way. Strengthening their governance to enable decisions to be taken collectively while recognising the accountabilities of constituent organisations is essential – and in some cases difficult.

Bolstering the leadership of STPs is also necessary to ensure they have the experience needed to move from planning to implementation. This means identifying leaders who can commit fully to work on STPs and the teams they will need to support them. It also means supporting the personal and professional development of these leaders and their teams.

Regulators and other national bodies must support system leadership through their actions as well as words to provide the clear and consistent leadership we have argued for.

Provider leadership

What we said

New care models and the organisational models described in the Dalton review require new styles of provider leadership. These must be supported by national bodies to avoid the wrong kind of regulation and to avoid leaders being deterred from applying for executive-level board roles.

What’s been done?

New models of care have changed the landscape of providers, not only with MCPs and PACS but also in acute hospitals. Four foundation trusts have so far been accredited to form groups or chains of hospitals as part of the acute care collaboration (ACC) vanguards. ACCs are more diverse than most of the other types of vanguards, comprising multispecialty chains, hospital group models and specialty-based franchises.

Among the ACCs, there is particular interest in work going on in London, Salford and Northumbria, where high-performing trusts are leading the development of hospital groups. As an example, the Royal Free in north London is working closely with other hospital trusts to reduce variation in clinical services and reduce costs through collaboration. One of the challenges in these and similar developments is to ensure the performance of lead providers does not deteriorate in the process of lending support to organisations in difficulty.

Another challenge is to develop a management model within hospital groups that will be more diverse and complex than even the largest of foundation trusts, combining leadership of the group with leadership of the hospitals that make up the group. It also means developing and strengthening clinical leadership and the management support on which successful clinical leaders rely.

There has been continued consolidation of trusts through mergers and acquisitions. These have often been driven by trusts experiencing severe financial and operational problems and in some cases critical reports from CQC. In at least one instance (Frimley and Heatherwood and Wexham Park), a merger led to improvements in performance in a relatively short time. This contrasts with other evidence that has highlighted the mixed and often disappointing experience of mergers.

What still needs to happen?

Hospital groups hold promise but are largely untested in the way they are being implemented in England. As in the case of the other types of vanguards, groups need time to develop and to put in place the leadership, governance and management models appropriate to their ambitions. National bodies also need to develop ways of assurance and regulation of these innovative provider models.

How might a transformation fund contribute?

How might a transformation fund contribute?

How might a transformation fund contribute?

What we said

NHS England should work with other national bodies to put in place a transformation fund to support NHS leaders and their partners to implement new care models. This should learn from experience in mental health and ensure that resources are used for transformation, not to keep existing service solvent.

What’s been done?

A Sustainability and Transformation Fund of £2.1 billion was established for 2016/17, with the vast majority (£1.8 billion) being used to cover provider deficits. The NHS shared planning guidance published during 2015/16 promised an increasing share of the fund to be put towards transformation for each subsequent financial year until 2020/21. The latest NHS planning guidance published in September 2016 has again earmarked £1.8 billion of the fund per year to help cover provider deficits in both 2017/18 and 2018/19.

Local systems are being asked to draw up ambitious plans for how they will transform care delivery while also reducing deficits. With most of the Sustainability and Transformation Fund being used on deficit reduction, little money is left for transforming services. Concern has been expressed that many STPs may not be realistic where they depend on investment in new services that is not available – for example, to strengthen out-of-hospital services in order to reduce reliance on hospital care.

Funds for capital investment are limited, and this may inhibit the implementation and spread of new care models.

What still needs to happen?

If the vision of the Forward View is to be realised at the pace originally intended, local systems need adequate funding to cover the cost of introducing a new system while still running an old one. Some vanguards reported a scaling back of their plans due to insufficient funding, and transformation funding will now also need to support all 44 STP footprints. Other ways of funding transformation should be explored such as releasing resources from the NHS estate and raising resources for capital investment from new sources.

Where next?

What we said

Implementation of the Forward View should involve a process of discovery and not design. There should be a commitment to real-time evaluation and learning throughout the process.

What’s been done?

The vanguards exemplify a commitment to discovery and not design. National bodies have supported local leaders in testing out the development of new care models and have avoided being overly prescriptive. This has unleashed a degree of innovation and commitment to improvement that is relatively unusual in the history of the NHS, and contrasts with increasing scrutiny and oversight of commissioners and providers to improve operational performance.

In May 2016, NHS England published a national evaluation strategy for the new models of care programme. The intention is to better understand which aspects of the new care models work and in what context, with the intention of drawing out lessons for the NHS. It includes a commitment to support vanguards to evaluate their own practice; a plan to commission an independent evaluation of the programme; and monitoring of efficiency and care quality metrics.

Work has been progressing to implement this strategy. The progress of vanguards is being measured against common metrics (for example, non-elective admissions, bed day activity, patients’ quality of life and patient involvement in care). These metrics were selected following discussions with vanguards as to which would best reflect their aims. The data is collected and analysed centrally and made available to vanguards to track their own progress.

Vanguards are also being supported to commission their own local evaluation and will select additional, local metrics that might provide a more detailed picture of the impact their new care model is having, for example by tracking efficiency (eg, delayed transfers of care, changes to permanent admissions to residential or care homes) and health and wellbeing (eg, staff and patient satisfaction).

What still needs to happen?

National bodies need to balance oversight and scrutiny of commissioners and providers in relation to operational performance with support for innovation to be led locally. They should continue to share learning from the new care models with the rest of the NHS and to clarify national rules on issues like procurement and tendering. They should also move rapidly to remove barriers to the more rapid implementation and spread of new care models.

The development and implementation of new care models must be based on thorough analysis of the risks involved and how these will be managed. National leaders should exercise patience to avoid a repetition of the difficulties that arose in the UnitingCare Partnership contract and to allow time for the foundations to be laid for new care models. They should also heed lessons from experience of integrated care in the United States which often failed because inadequate attention was paid to implementation and execution of plans.

Conclusion

Progress in implementing the policy changes needed to support the Forward View has been mixed. Work to establish new care models and STPs has developed furthest, alongside plans to devolve more responsibility to public sector leaders, such as in Greater Manchester. These initiatives have begun to develop the system leadership required to transform services in the complex and fragmented structures currently responsible for commissioning and providing health and social care, albeit with more to do to build on achievements to date.

Some progress has been made in developing more joined-up regulation between NHS England and NHS Improvement, exploring how CQC should regulate across organisations and services, and identifying innovations in payment systems to support new care models. NHS Improvement has been supporting local leaders by issuing guidance and running webinars and events. Much remains to be done in this area as well as to strengthen quality improvement and leadership development and to develop the leadership needed in emerging hospital groups. Uncertainties about procurement and tendering also need to be clarified.

One of the lessons from the first two years of implementing new care models is that new forms of governance are required to support collective decision-making between organisations. But putting in place new forms of governance – often involving innovations in contracting and organisational form – has proved challenging within the existing NHS environment. As vanguards and other new models of care continue to develop, local areas are likely to reveal obstacles to collaboration that only national bodies in the NHS can remove – and in some cases may require changes in legislation.

The area of greatest concern is lack of funding to support transformation. Almost all of the additional funds available to the NHS in 2016/17, the year of ‘frontloading’ the NHS Spending Review settlement, have been used to sustain existing services, specifically to reduce deficits in NHS acute providers. NHS leaders both nationally and locally have been preoccupied with sustainability because of the growing pressures on health and social care and evidence that NHS organisations are missing key targets for patient care. Much less of their time has been dedicated to transformation than might have been expected given the central importance of the Forward View.

This matters because the pressures on health and social care will not be tackled simply by additional funding, staff working harder, and patching up existing services through 'sticking plaster' solutions. These pressures result from a growing and ageing population placing ever greater demands on a system already under huge strain. This is evident in year-on-year increases in A&E attendances and emergency admissions to hospital, high bed occupancy rates, and rising delayed transfers of care. There is also evidence of rising demand for services outside hospital, for example in GP consultations.

The rationale for new care models like MCPs and PACS is precisely that they hold out the prospect of moderating rising demands for care by focusing on prevention, early intervention, admission avoidance and support for people to remain independent in their own homes. They do so through greater integration of care and by aspiring to shift investment into the community to provide alternatives to care in hospitals or care homes. Reports on the work of the vanguards illustrate what this means in practice and offer hope for the future.

The challenge is that developing alternatives to care in hospitals and care homes requires investment, which is currently in short supply. There is a parallel with the transformation of mental health services that started in the 1970s and resulted in a much reduced role for hospitals and a much stronger focus on care in the community. Mental health services were transformed as successive governments provided funding to pump-prime investment in community services, which over time led to the closure of many of the former asylums and the establishment of a very different model of care.

The transformation of mental health services was not without its difficulties, either at the time or now. Nevertheless, it shows that major changes of the kind foreshadowed in the Forward View are possible with adequate funding for transformation and if sufficient time is allowed for them to be planned and implemented. With two out of the five years covered by the Forward View already elapsed, the lessons are clear and need to be acted on with urgency. Leaders at all levels need to redouble their efforts and recognise that transformation holds the key to dealing with the sustainability of services.

Further reading